Ten respondents from among those who had completed the survey (n = 20) were interviewed. We classified themes related to reason for turnover as either avoidable or unavoidable (see Table 1). Sub-themes under avoidable turnover included lack of manager support, growth opportunities; burnout/workload; tension/conflict, and; hours of work. Sub-themes under unavoidable turnover included life-stage/life-events and geography. We also identified themes related to consequences of turnover including: burnout/workload, client/patient impact, tension/conflict, cost and gap-specific.
Table 1: Themes Identified
Consequences of Turnover
- Managerial support: whether due to absence, incompetence or manager overload
- Growth opportunities: lateral, vertical, towards “prestige”
- Tension/conflict: including inter- and intra-professional and undervaluation of the RD role
- Hours of work: full- or part-time
- Burnout/workload: supervisor- and/or team
- Client/patient impact
- Team dysfunction
Avoidable turnover: All ten managers addressed manager support as a factor contributing to (or preventing) high turnover; they identified both supportive and unsupportive practices and approaches. Manager characteristics and/or practices identified as contributing to higher turnover included inflexibility (P02,04,06-08); micromanagement (P02,07,08), such as “when the manager is too involved and wants to control all of their [an RDs] activities” (P07); unresponsiveness (P04,06,07), and; inattentiveness (P04,06,07). Dictatorial management styles were identified as hindering employee retention (P04,06), while providing autonomy (P05,07,08) — including the freedom to make mistakes— was associated with reduced turnover.
A trusting relationship between employee and manager was the most frequently mentioned factor positively influencing retention of RDs (P02,05-07,09) – “some of the things dietitians have told me is that…they feel like they know that we’ll go to bat for them, that we will stand for them when it’s difficult” (P07). Managers felt that their RD employees particularly valued their responsiveness in answering questions and in helping them to solve problems they experienced (P03,05,07). This included timely action to take RDs’ problem(s) up as high in the organization as needed to achieve a solution. Managers recognized that staff also appreciated a “listening” ear, with no expectation of specific action by either manager or RD (P01,07,09).
Practices associated with employee retention by managers included: providing informal opportunities to “touch base” (P01, P07); exhibiting transparency by clearly outlining expectations and providing rationale for either the status quo or new initiatives (P04,07,09); making time for collaborative problem-solving sessions (P04,05,09); recognizing RD accomplishments and value (individually and collectively) (P04,05); demonstrating empathy during interactions with staff (P06,07); treating staff equitably (P05,09,10), and; providing active support for RDs to achieve personal and professional goals (P04,10). Managers (P06, 07) felt that an understanding of the role of the dietitian, frequently based on personal experience as clinicians in similar roles, was of value in retaining staff. One manager summarized many key points as follows:
“I think a leader needs to let people do their work… on their own and learn on their own from some of their mistakes… it needs to be a safe environment to try new things, to challenges one's self and then people grow. If not, they leave." (P05)
The presence or lack of opportunities for growth, whether expressed as a desire for expanded skills and expertise, for prestige, or for advancement was reported as a factor impacting turnover by nine of ten managers. Specifically, as P01 noted, RDs desired “to have education that sustains practice.” Managers (P02,03,05) acknowledged that RDs often sought “more challenging roles” (P02), sometimes in a particular specialization or area of passion for them (P08). Such specialization may not have been attainable or possible within the employing organization. One manager stated explicitly:
“sometimes I think we all move to other health authorities just because there’s some interesting positions –there’s a potential to specialize in different areas that you couldn’t do here” (P03)
Managers most commonly reported prestige or preference as linked to a particular facility (P05,08,09), rather than as associated with an individual program or field of practice. Manager P05 commented on the popularity among RDs of working at the largest, acute care hospital and how that had led to smaller, community hospitals losing “some of their dietitians because they want to come here.” Holding a specialized position at this site was associated with additional opportunities for growth, development and recognition.
In the case of pediatrics, P09 noted that there was a certain cachet to treating children who “will do anything they can to get better” with “parents who will do anything it takes to make their kids better.” She noted that in adult care:
“sometimes the conditions are complex and chronic and sometimes actually coming from choices in the past” – “being told you [the patient or client] have to change things is not always welcome, especially when it’s having to do with food or alcohol or anything like that” (P09)
In relation to advancement, manager P03 noted a lack of positions to form a career ladder within their health authority. In smaller health authorities, there may be very limited turnover in the few existing advanced RD roles, which makes it infeasible for others to ever advance within the organization.
Eight of ten respondents identified burnout and heavy workload as contributors to turnover in their interviews. One manager (P01) reported “workload that’s not congruent with the amount of hours that are expected.” As a result, staff can experience “extreme stress or distress coming to work” as there “is not enough time to finish their work” (P04). Two managers (P02,03) noted that uneven workload distribution across positions contributed to turnover.
Tension and conflict were noted as factors integral to turnover by seven of ten respondents. Three referred to conflict within the profession, five to interprofessional conflict and two to conflicts in relation to undervaluation of the RD role. Conflicts among RDs can result from having to share “very small cramped” (P06) workspace. Such conflicts can be particularly damaging as “they [RDs] are supposed to share their workload, cover for each other” and “work cooperatively.” For some returning to the dietetic department could help them to “escape” from a hypercritical environment – “like the gossiping and whatever goes on on the unit” (P03). This manager suspected that:
this “kind of escape…helps people to be able to stay longer in their positions and have less turnover because…they have support from their coworkers to not get sucked into that kind of attitude” (P03).
Interprofessional conflict was often closely tied to undervaluing the role of the RD. Problems can arise when “other care providers” try “to do the work of the dietitian” or are not “willing to accept the dietitian as the nutrition professional” (P07). One manager (P07) commented on the current climate, where “everyone thinks they can do the nutrition component” and how this can leave RDs feeling frustrated. Another manager noted that in the past, on their eating disorders unit, a lack of trust had developed when the RD:
“would make a recommendation, leave the unit, go see another patient…come back the next day and their recommendation would not be followed. Something else would have been suggested either by the nurse or pharmacy, physician, whatever, so they—it got to a point where they felt discouraged…why am I trying so hard when I have such a heavy caseload to do my assessments and all those recommendations when as soon as I turn, somebody goes in and changes it and they don’t even let me know they disagree, they just go ahead and change it.” (P09)
Four of ten managers attributed some turnover to the full-time equivalence of available positions, with some RDs expressing a desire for part-time and others for full-time. Manager P01 noted that the “part-time positions don’t seem to turn over quite as much.” In their experience, once employees had children they tended “not to want to come back full-time” and, if they did come back full-time, they moved “into a part-time position as soon as they” could. Despite these positions being “coveted from a staff perspective,” the organization did not “want part-time positions” or job shares (P01). In fact, this manager’s organization had merged many part-time positions to form full-time positions (P01).
In contrast, a manager of RDs in rural areas (P02) reported seeing higher turnover in part-time positions, attributing this, at least in part, to the employee-paid expense and time associated with travel to and from work sites. A preference for full-time was echoed by P06 and P10, with both noting that RDs began in part-time positions and remained only until a full-time position became available.
Unavoidable turnover: Life-stage was noted by seven of ten managers as a reason for turnover. It is well known that dietetics is a female dominated profession and many RDs are in the “the time of their lives that they want to start a family” (P04). Employees will also leave their positions “because their family is moving” (P05) or “their husband gets transferred” (P07). Retirement was also considered an unavoidable reason for turnover. In some instances the health authority can be blindsided by how much a retiring RD actually did: e.g., “when they were trying to package her responsibilities they didn’t even know all the jobs she did and some didn’t get done and there was risk” (P06).
Geography, or the location of the RD position, was another factor contributing to turnover. In some health authorities, many new hires were making a move to a more rural part of Canada where they may feel isolated. If “people are here without any family or any of their friends, sometimes that is kind of the issue of why they moved away” (P03). In other cases, it may be that the geographical coverage area is too large:
“When you give a dietitian too much space to try and cover it is hard for them to make meaningful connections in all of those communities…” and “until you have someone who actually wants to be in that community, who is from that community, who’s got a partner that lives in that community [laughs]…you have lots of turnover in that community.” (P07)
Consequences of turnover: Burnout and high workload were identified not only as triggers, but also as consequences of turnover. All ten managers indicated that burnout and high workload related to turnover impacted their own workload and job quality, while nine identified similar effects on remaining team members (including RDs). A common sentiment was that managers were “constantly recruiting new staff” (P01). Recruitment and hiring were “quite a process…from getting approvals and getting job postings to interviewing” (P02), training and orientation.
These tasks can take “time away from actually leading practice, addressing practice issues and looking at…expanding programs, securing funding…making proposals to advocate for the profession” (P04). This can perpetuate circumstances where coverage of particular units or programs is insufficient to meet the dietetic needs of clients and patients.
Various impacts on the team were reported to result from having to pick “up the slack for people that have gone on” (P02) and/or from the increased workload associated with training new staff (P02,03,06,09,10). Staffing changes can create a “domino effect” (P09) where multiple people shift positions as a result of the first turnover event. P09 noted how the team must adapt when there is turnover and learn to “trust the new person coming in” (P09); frequent turnover can “decrease trust from the unit level in our department because we aren’t able to meet the demands of the unit” (P10).
All ten respondents identified impacts on clients and patients resulting from RD turnover. Commonly noted impacts included: delayed nutrition care (P02, 03,04,06,10), in particular delays triggered by lengthened waitlists (P03,04,06,10) and cancelled clinics (P04); prolonged hospital stays (P02,04), which may result from delayed discharge planning (P04) and/or malnutrition (P10), and; less skilled nutrition care while inexperienced RDs build experience (P07,09). These impacts were notable even when there was no gap in service as new RDs are “usually less efficient at first so there’s still fewer people getting seen or it takes longer to get to them” (P03). A risk of delaying RD-provided nutrition care, particularly in outpatient settings, was raised by P06:
“when people are waiting a long time to see a dietitian…I believe that they will search out different forms of information and there is a whole pile of it that is not a very high quality in the public sphere, and I think that people may or may not engage in seeing a dietitian if they have to wait too long” (P06).
Additionally, as noted by P10, patients or clients with time-sensitive issues/concerns, such as prenatal clients, bear greater risk as a result of delayed nutrition care.
Several respondents (P01,07,08) indicated that “patients have seen lots of different people [RDs] and they feel that there’s a lack of continuity” (P01). P08, speaking to practice in the long-term residential care setting indicated that “residents develop relationships with the staff because” they “provide care to people through an extended time period” and that there may be “some frustration on the part of patients that they have to catch people up to what their history has been” (P08)
Three managers commented on team dysfunction that could result from RD turnover. In rural locations, frequent turnover in what may be the only position serving the community can result in loss of “the trust of the community”(P07) so that the RD is no longer sought out to participate in client-care or program development because community members begin to think: If the RD is only going to be here “a couple of months…why would we bring her [or him] into these conversations” (P07)? This can result in the loss of “opportunities to make a difference in the community” (P07). In other cases, it may be that non-RD staff step in to fill the void during recruitment and orientation post-RD turnover and then have difficulty stepping back once the new RD is practice-ready (P09).
Managers (three of ten) also called attention to the cost of turnover. P01 noted how when turnover is high she has “to train more,” which drains her budget for RD relief. This meant that remaining RDs may no longer have had access to workload relief or back-fill when needed.
Some of the impacts of turnover were gap-specific, meaning that they occurred only when there was a vacancy in the position while awaiting a replacement RD. Gaps in service are not always the result of failed searches for new staff; “there is often gap in service between the time a person leaves to the time a new person can come in” (P02). In rural areas candidates can “take the better part of a month” before they are able to report to work (P03). Rural communities can also experience long stretches without access to an RD – in P07’s observation, communities “get used to not using the dietitian and then…when we do get a dietitian back in that position, they [the RD] have to rebuild the trust and the whole practice that the previous dietitian had.”